A. Integration

CRCS programs may be more successful when they are fully integrated into multi-service organizations and the greater HIV prevention community, although single-service agencies with strong collaborative relationships in the service community are also good CRCS service providers.

Integration means

Staff of your agency and other agencies are aware of and support the CRCS program CRCS staff work with other staff from your agency and from other agencies to support and provide services to clients

Integration is fostered by

Locating CRCS counselors within or near other non-CRCS services that clients might utilize (e.g. clinic, food bank, housing, case management offices Marketing the program internally and to other agencies Regular meetings between CRCS staff and other agency staff or other agencies for developing protocols for collaboration, programmatic exchanges, or case conferences

Integration doesn’t happen without

Management and supervisory attention to and support of close working relationships among staff to support clients Making sure staff and clients understand the differences between CRCS and other programs and services

B. Staffing

Well trained supervisors and counselors are essential to the success of any CRCS program. All CRCS counselors and supervisors should have, at a minimum, training in pre- and post-test counseling, which provides a standard client-centered approach to HIV prevention³. One model for this is Project RESPECT⁴.

Program managers and supervisors

Program managers and supervisors are a crucial part of CRCS. We strongly encourage these CRCS staff to attend CRCS trainings, particularly the management/supervisor trainings⁵. In addition to strong administrative supervision, agencies should provide “clinical” supervision. A clinical supervisor should have experience working with HIV issues, and, depending on the population at risk, mental health or substance abuse training or experience may also be critical.

In a multi-service organization and across agencies, CRCS works well when supervisors support CRCS by

• Finding ways to educate others in the organization about CRCS
• Organizing one-on-one meetings with supervisors of other units
• Presenting on CRCS to staff in other agencies

Supervisors should also keep in mind the potential for resistance to CRCS in organizations where case management is funded by Ryan White, Medicaid, SAMHSA or other systems. This resistance can be overcome when staff in these programs experience the ways in which CRCS, which works with the most challenging clients, can support other case management services and help decrease workloads.

Initially

Supervisors should help develop an implementation plan that is appropriate for the agency and agency’s clients.

Thereafter

Supervisors should review active case files and meet with CRCS counselors regularly. Supervisors should also watch for opportunities to increase staff skill levels through direct observation, role play, and feedback.

CRCS counselors

CRCS counselors work with the highest risk clients on very difficult issues. Mental health and substance use are the most frequently reported challenges to risk reduction among CRCS clients – thus the need for CRCS counselor expertise and referrals to services in these areas.

Lessons from the Field

Successful CRCS counseling appears to depend more on cultural competency (familiarity with the community and ability to communicate effectively with the client) and knowledge of basic counseling techniques (reflective listening, building rapport, motivational interviewing) than on any specific educational level. However, because of difficult psychosocial issues presented by some clients, particularly mental health issues, some agencies prefer that their counselors have at least a Master’s degree or request that clients be referred to mental health specialists within or outside of the agency. Experience with clients who would benefit from substance use treatment will also be a helpful, if not necessary, background for many CRCS counselors. Prevention counselors should also consult with clinical supervisors regarding clients who present particularly challenging circumstances.

Regarding caseload, a full time CRCS counselor should have between 12 and 20 active clients at one time. This caseload is smaller than caseloads for typical case managers. The smaller caseload allows for intensive recruitment and engagement activities and more frequent and intensive risk reduction sessions. Additionally, counselors will likely spend time contacting clients, to assure that they return for services. Caseloads will be larger for CRCS counselors who do not provide case management services.

CRCS counselors are

Respectful Patient Resourceful & creative Empathetic Practical Non-judgmental Ethical Familiar with the “lingo” used by the population being served

CRCS counselors’ knowledge, skills, and abilities include

Good listening Networking Knowledge of HIV/STD-related risks and pertinent prevention strategies Comfortable communicating about sensitive topics (sex, drug use, sexual orientation Ability to help clients develop risk reduction skills and strategies Effective communication Advocacy Cultural and language competency

CRCS counselors should

Be experienced working with challenging clients Be comfortable talking about sensitive issues Receive training in CRCS, and particularly in intensive risk reduction counseling

C. Coordination of Service Providers

What do we mean when we talk about coordination and collaboration?

It takes time and energy to build effective collaborative relationships – and time and energy are often in short supply. This is especially true given the very real and constant demands of working with CRCS clients whose needs are often extraordinary. However, the benefits of collaboration are important to CRCS providers and clients – improved service delivery, reduced stress, and better use of financial and human resources.

Collaboration is a process of participation through which people, groups, and organizations come together in a mutually beneficial and well-defined relationship to work toward results they are more likely to achieve together than alone.

An agency is able to enhance its services through collaborative sharing of resources with other agencies. Collaborating agencies focus on specific efforts or programs, exchanging information and altering activities to derive mutual benefit and achieve a common purpose.

Coordination requires planning, clear roles and a division of labor, and open channels of communication between organizations. An example of coordination would include referral agreements between HIV counseling and testing centers and primary care clinics.

Remember to avoid overlap with existing case management services, and make sure that your clients know whom they can go to for which services. And remember to have clients sign release forms, according to your agency’s guidelines.

D. Environmental & structural issues

The CRCS counselor should have access to a private space in which to meet clients, where clients will feel comfortable talking about high-risk behaviors.

Lessons from the Field

If possible, locate the CRCS counselor near non-CRCS services used by CRCS clients -- this provides an opportunity to follow-up with clients who have difficulties staying engaged with the program and is more convenient for clients. Locating services near each other also encourages interaction of staff in support of clients. Consider offering CRCS appointment times that are outside normal business hours (in the evenings or on weekends) in order to accommodate clients’ work schedules. Be willing to provide services to clients where they are more comfortable receiving them, outside of your agency if need be. This will allow CRCS counselors to reach clients who might otherwise have no contact with the agency. However, your agency’s staff and client safety protocols should be in place before you provide off-hour, off-site services. Safety protocols may include - Assess the safety and client confidentiality situation in any venue Make sure your supervisor knows where you are and how to reach you Meet at safe spots, such as safe public parks, restaurants, coffee shops—know your territory! Don’t go into a home unless you know who else will be there and you know the client well It’s important to have a policy and procedures for handling potentially dangerous situations.

Naming the program

Many agencies that provide CRCS have found it helpful to change the name of the CRCS program to suit the community that they serve. The components of CRCS should not change, but the name can be more appealing and meaningful to your community.

For example –

E. Incentives

Incentives may encourage client participation – but your goal is that clients come to value reducing risk and living healthier lives. Your agency should decide

• If incentives will be useful for recruitment and retention
• If incentives are a good way to maximize existing resources; that is, if incentives result in better participation and lower no-show rates, and therefore better utilization of staff time (counselors do not wait for clients who don’t show up)

Some agencies choose to provide incentives for activities related to monitoring and evaluation (e.g., baseline and follow-up assessments), because these activities often are over-and-above a commitment to the intervention program in general or to behavior change specifically. Other agencies start with incentives and decrease them systematically, as clients become more engaged. You should clearly explain your agency’s incentive program to potential clients.

Agencies tend to define incentives differently. For some agencies, transportation tokens are not considered incentives, but are seen as supporting clients to reach their program participation objectives.

Examples of incentives include:

• Transportation support (bus ticket, subway or rail card, taxi voucher)
• Food voucher or access to food pantry
• Phone card
• Gift certificates
• Movie pass
• Hygiene kits
• T-shirts
• Small monetary reimbursement

Lessons from the field

Incentives may be given at completion points, for example, when clients reach even seemingly small or minor objectives. An incentive program should be sustainable – decide on incentives given client needs and the resources available to your agency for use as incentives. Note that some agencies decide NOT to provide incentives, expressing the view that reaching behavioral objectives should be its own reward Other agencies maintain that clients come at first for the incentives and stay for the program Caution! Some forms of incentives can be used to purchase alcohol, tobacco, or other drugs

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³http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5019a1.htm
⁴http://www.cdc.gov/hiv/topics/research/respect
⁵http://depts.washington.edu/nnptc